How To Use HCPCS Code G8854

HCPCS code G8854 describes the documentation of reason(s) for not objectively reporting adherence to evidence-based therapy. This code is used in cases where patients have valid reasons for not following the recommended therapy, such as those diagnosed with a terminal or advanced disease with an expected life span of less than 6 months, patients who decline therapy, patients who do not return for follow-up at least annually, patients unable to access or afford therapy, or when the patient’s insurance does not cover the recommended therapy.

1. What is HCPCS G8854?

HCPCS code G8854 is a specific code used in medical coding to identify the documentation of reasons for not adhering to evidence-based therapy. It helps healthcare providers accurately report and track instances where patients are unable or unwilling to follow the recommended treatment plan.

2. Official Description

The official description of HCPCS code G8854 is “Documentation of reason(s) for not objectively reporting adherence to evidence-based therapy.” The short description for this code is “Reas no adhere therapy.”

3. Procedure

1. When documenting the reason(s) for not adhering to evidence-based therapy, healthcare providers should clearly state the specific reason(s) for the patient’s non-compliance.
2. Providers should include detailed information about the patient’s diagnosis, prognosis, and any other relevant medical factors that contribute to the decision not to adhere to therapy.
3. It is important to document the patient’s informed consent or refusal of therapy, if applicable.
4. Providers should also document any discussions or counseling provided to the patient regarding the risks and benefits of the recommended therapy.
5. Ensure that the documentation is clear, concise, and supports the medical necessity for not adhering to evidence-based therapy.

4. When to use HCPCS code G8854

HCPCS code G8854 should be used when there is a need to document the reasons for not objectively reporting adherence to evidence-based therapy. It is important to use this code only in cases where the patient meets the specific criteria outlined in the official description, such as having a terminal or advanced disease with a life expectancy of less than 6 months, declining therapy, not returning for follow-up at least annually, being unable to access or afford therapy, or having insurance that does not cover the recommended therapy.

5. Billing Guidelines and Documentation Requirements

When billing for HCPCS code G8854, healthcare providers should ensure that the documentation supports the medical necessity for not adhering to evidence-based therapy. The documentation should clearly state the reasons for non-compliance and provide any relevant medical information that supports the decision. It is important to accurately code and document the patient’s condition and the specific reasons for not adhering to therapy.

6. Historical Information and Code Maintenance

HCPCS code G8854 was added to the Healthcare Common Procedure Coding System on January 01, 2012. The code’s official description was changed on January 01, 2024, indicating a change in the long description of the procedure or modifier code. The pricing indicator code for this code is 00, which means that the service is not separately priced by Part B. The multiple pricing indicator code is 9, indicating that the value is not established or not applicable as HCPCS is not priced separately by Part B.

7. Medicare and Insurance Coverage

The coverage of HCPCS code G8854 may vary depending on the payer. Medicare and other insurance providers may have specific guidelines and policies regarding the reimbursement of services or supplies associated with this code. Providers should review the payer’s guidelines to determine if this code is payable and how it is priced.

8. Examples

Here are some examples of when HCPCS code G8854 may be used:

1. A patient diagnosed with terminal cancer who declines chemotherapy due to personal beliefs.
2. A patient with advanced dementia who is unable to follow a prescribed physical therapy regimen.
3. A patient with a rare genetic disorder who cannot afford the expensive medication recommended for treatment.
4. A patient with limited mobility who is unable to access a specialized therapy facility.
5. A patient whose insurance does not cover the recommended therapy, making it unaffordable.